Adirondack Equine Assisted Psychotherapy Intake Form Page 2
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2Treatment History: (previous diagnoses outpatient/inpatient treatment; alcohol/substance
abuse history; treatment interventions, effects, compliance, outcome)_____________________
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Social History: (employment; school; teacher; IEP/504; education level; military history; legal
status)_________________________________________________
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Family History: (family history of mental health/substance abuse; family make up;
custody)_____________________________________________________________________
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Current Medications: (names, doses, side effects)___________________________________
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Allergies:____________________________________________________________________
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Diagnosis:
Axis I:_______________________________________________________________________
Axis II:______________________________________________________________________
Axis III:______________________________________________________________________
Axis IV:_____________________________________________________________________
Axis V:______________________________________________________________________
Level of Care:________________________________________________________________
Treatment Plan: (treatment goals/objectives)________________________________________
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